Fax Order Form - Abacus Diagnostics, Inc.

ORDER FORMThis is a fillable form. Fill it online, save it on your computer and email it to order@abacusdiagnostics.com .You may also fax it at (818) 716-9471.Date_____________Customer No.____________(if available. If you do not know or do not have it, please leave it blank)Catalog # DescriptionType308332 ABAcard® p30: Semen Identification (25 test/kit) + Lab Use404334 ABAcard® p30: Semen Identification (25 test/kit) + Crime/Lab useQty ofkits/orderPrice per kit(US$)Total (US$)488099 ABAcard® p30 : Semen Identification (10 test/kit) + Crime Scene433212 ABAcard® p30 : Semen Identification (1 test/kit) + Crime Scene708424 HemaTrace® : Human Blood Identification (25 test/kit) + Lab Use808426 HemaTrace® : Human Blood Identification (25 test/kit) + Crime/Lab use599010 HemaTrace® : Human Blood Identification (10 test/kit) + Crime Scene511871 HemaTrace® : Human Blood Identification (1 test/kit) + Crime Scene810923 Hemascein :Latent Blood Detection, ID, Collection Kit (500 ml) + Crime/Lab use800121 Hemascein : Latent Blood Detection Kit (500 ml) + Crime/Lab use903295 SALIgAE® : Saliva Identification (10 test/kit) ++ Crime/Lab use259225 Uritrace : Urine Identification Kit (25 test/kit) + Crime/Lab use251115 Uritrace : Urine Identification Kit (15 test/kit) + Crime/Lab useCSWAB50 Containment Swab (C-Swab) (50 pcs/case) + Crime/Lab useCSWAB400 Containment Swab (C-Swab) (400 pcs/case) + Crime/Lab useSW2A50 FAB-SWAB (50 pcs/case) + Crime/Lab useSW3B400 FAB-SWAB (400 pcs/case) + Crime/Lab useSales Tax (Only CA Customers)ShippingOtherTotalNote: Each kit contains individually wrapped units..+ Kit Storage temperature is at room temperature. ++ Kit storage temperature is 2-8 o C.If Customer number is known as above, it is not necessary to fill out the billing/shipping information unless ithas changed recently.BillingShippingAddress:Address:Contact:Contact:Phone: Fax: Phone: Fax:Comments:

Date___________Customer No.____________(if available. If you do not know or do not have it, please leave it blank)Payment mode Bill us . PO# is _____________________ Credit Card (Visa/Mastercard/Amex) #_____________ Exp:_ _ _ _ _ CVC:Name on Credit Card__________________________________________________This order was placed by____________________Phone________________Date________o The PO can be faxed at (818) 716-9471 or mailed at Abacus Diagnostics, 6520 Platt Ave Unit #220,West Hills,CA 91307USA Attention: M/S FONL-0928FCRo The purchase order may also be placed over the phone at (818) 716-4735o You may email your request to order@abacusdiagnostics.com Standing Orders : Acceptedo Delivery: Under normal circumstances, all orders are usually shipped within 1-3 working days.You may fax this order form to (818) 716-9471For any additional questions, please call (818) 716-4735 or toll free at (877) 225-9900